Provider Demographics
NPI:1881674752
Name:KINNETT, STEVEN CLARK (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:CLARK
Last Name:KINNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 N GREENWOOD ST
Mailing Address - Street 2:SUITE 406
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2644
Mailing Address - Country:US
Mailing Address - Phone:719-584-7310
Mailing Address - Fax:
Practice Address - Street 1:1619 N GREENWOOD ST
Practice Address - Street 2:SUITE 406
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2644
Practice Address - Country:US
Practice Address - Phone:719-584-7310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28014225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01280148Medicaid
CO01280148Medicaid
COC49991Medicare ID - Type Unspecified